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Improvement Plan: TITLE OF WORK BEING UNDERTAKEN

1. WHY ARE IMPROVEMENTS NEEDED?

a) Background & Context

Relevant details about the service / department
What is the size, scale & frequency of the problem? Other key info?

b) Problem Statement:

What is the ‘pain’?
What is the gap between the current and desired situation?
What is the impact of the gap (how does it relate to strategic priorities)?

NOT – solutions, causes or symptoms of the problem

2. WHAT IS CURRENTLY HAPPENING?:

What does the data tell us is currently happening? Quantitative data + qualitative e.g. complaints, patient / staff feedback
What is the agreed process vs what actually happens
Process mapping – the agreed process be Vs what actual happens

4. WHAT DO YOU WANT TO ACHIEVE?

a. Describe the vision for an improved situation?:

b. What is your SMART Aim?:

Specific, Measurable, Achievable, Relevant, Timebound#

c. What are the key things / driver that will help you to achieve your aim?:

Driver diagram

3. WHAT ARE THE FACTORS CAUSING THE PROBLEM?:

Pareto charts – top contributors
Identifying waste
Systems thinking & human factors
Outcomes from patient safety learning responses
5 Whys / Root cause analysis (e.g Fishbone diagram)
Understanding the perspectives of others

6. WHAT CHANGES CAN YOU MAKE THAT WILL RESULT IN AN IMPROVEMENT?

a. Change ideas?:

Driver diagram – what changes can help to achieve each of your drivers?
Ideas generation
Thinking from the perspectives of others e.g. Brand thinking

b. What will you prioritise which change ideas to try first?

PICK chart

5. HOW WILL YOU KNOW A CHANGE IS AN IMPROVEMENT?

Measurement plan

Outcome – are you having the desired impact?
Process – are the required processes happening?
Balancing – are there any unintended consequences?
What data do you need? Where will it come from? How often will you collect it?
How will you analyse it? How / where will it be displayed (SPC, Run charts or other) reported and used?
Your driver diagram will help to identify key measures

7. PLAN & DO – testing your change ideas

Initial plan

what actions need to happen
by when & by who?
What is in & out of scope?
Is it within your control? Does it require escalation?

Think about why you have selected your actions, how will they help you to achieve your aim? Are they the right actions?

How will you get others on board with your plan?

8. STUDY & ACT – analysing the impact of your change ideas and and deciding next steps

a. What do the measures tell you? What insights have you gathered?

b. What will you do next? - insights / learning / scale & spread

Understanding the issue

The Model for Improvement – 3 questions

The Model for Improvement - PDSA

Key stakeholders: Who is Responsible for doing the work? Who are you Accountable to? Who do you need to Consult with? Who do you need to keep Informed? Use Stakeholder map and engagement plan

Follow the hyperlinks to useful tools & templates for each section

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